Case 3 Progress Note

Morning Progress Note

Subjective

Pt returned from unsuccessful AFib ablation this morning without issue. Pt feels tired currently denies chest discomfort.

Hospital Course

60 YO Male PMH of Afib, HTN, HLD, DM2, BPH directly admitted for elective Afib ablation.

Initial vitals Tm 36.8, HR 96, BP:120/80,  RR18, sat 96% on room air. CBC and Chem 8 within normal limits. EKG AFib rate 99 QTc 390. On admission pt denies shortness of breath, chest pain or palpitaitons

HOME MEDICATIONS 

  1. Aspirin 81 mg Tab, 1 by mouth daily
  2. Atorvastatin 20mg daily
  3. Amlodipine 10mg daily
  4. Coreg 12.5 mg tablet, 1 by mouth two times daily
  5. Amiodarone 200mg daily
  6. Hydralazine 25mg tablet, 1 tab by mouth every 8 hours
  7. Famotidine 20mg daily
  8. Metformin 500mg Q12H

HISTORIES

  • Past Medical History:  As above 
  • Family History: Mother: AFib, Father: Diabetes
  • Procedure History: Procedure History:  None
  • Social History: Alcohol: Denies Tobacco: Former smoker, 50 pack years, quit 5 years ago  Illicits: Denies   

REVIEW OF SYSTEMS:

  • Gen: Tired, somnolent
  • Resp: Denies SOB
  • Cardiac: Denies chest pain or palpitations
  • ROS somewhat limited due to somnolence post procedure

PHYSICAL EXAMINATION

  • Vitals Signs BP 100/70, HR 80, RR18, O2 92% on room air
  • General: Somewhat somnolent 
  • Eye: Pupils are equal, round and reactive to light, Normal conjunctiva.   
  • HENT: Normocephalic, Oral mucosa is moist.   
  • Respiratory:  Symmetrical chest wall expansion, Clear To Auscultation Bilaterally
  • Cardiovascular:  Normal rate, Irregular rhythm, distinct heart sounds difficult to appreciate
  • Gastrointestinal:  Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.   
  • Integumentary:  Warm, Dry, Pink.   

IMPRESSION AND PLAN

Impression: 

60 YO Male PMH of Afib, HTN, HLD, DM2, BPH directly admitted for elective Afib ablation.

Plan: 

Atrial Fibrillation/HTN/HLD

  • Unsuccessful AFIb ablation
    • Pt is currently still in AFib
  • Continue with Amiodarone consider switching to Tikosyn
  • Monitor on Tele in CACU
  • C/w Hydralazine, Coreg and amlodapine
  • F/u post procedure Echo

DM2

  • Hold metformin while in patient

 Dispo: D/c home tomorrow after observation post procedure

DVT PPX: Resume Heparin subq tonight

FULL CODE